Inspection on 24/04/07 for Island Place

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Island Place 21/04/09

Island Place 15/10/08

Island Place 21/05/08

Island Place 05/06/06

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Island Place Gooding Avenue Braunstone Leicestershire LE3 1JS Lead Inspector Rajshree Mistry Key Unannounced Inspection 24th April 2007 09:40 Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Island Place Address Gooding Avenue Braunstone Leicestershire LE3 1JS 0116 2855518 0116 2855518 islandplace@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 36 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (36) of places Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 5th June 2006 Brief Description of the Service: Island Place is registered to accommodate up to 36 residents in 10 apartments and is part of the Prime Life Group. Car parking is available to the front of the home and is a 10 minutes bus journey to the town centre and Fosse Park. The living area is located over three floors accessed through the main reception and entrance to the home. The office, staff room, the large communal lounge and kitchen are located on the ground floor. The upper floors are accessible via the stairs or the passenger lift. The flats accommodate either three or four people who have a communal lounge, kitchen and dining area and two shower/ toilet facilities. All the bedrooms are individual in character with furnishing and fittings to compliment. The home’s brochure provides information about the service to prospective and current residents and includes the ‘service user guide’ and terms and conditions of the stay could be made available in other languages and formats. Fees payable range from a minimum of £296.00 and may increase in accordance with the assessment of care needs carried out. There are additional costs payable such as transportation, activities and personal items. The CSCI published inspection report would be available at the home and referred to in the home’s brochure. The people who live there are informed of the CSCI inspection individually or in small groups discussions. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the pre-inspection questionnaire, and Comment Cards sent to service users, relatives and General Practitioners by the Commission for Social Care Inspection. The unannounced site visit commenced on the 24th April 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Island Place. Three service users were selected and discussions were held with them. Discussions held and observations were made of other service users who were not part of the ‘case tracking’ process. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of team meetings. The CSCI sent out thirty-six Comment Cards to service users, of which 36 were returned. Service users completed the Comment Cards independently or with some assistance of friends or the Care Management Team. Three Comment Cards were sent out to General Practitioner and one was returned. The comments indicated staff followed instructions, sought advice when necessary, had no concerns about the management of medication and was generally satisfied with the overall care provided to the service users. Comments incorporated within Service Users Comment Cards and direct comments included: “Communicate with different agencies” “I cook my own food” “ . . . has talked about the supported needed when I moved into the home, preferred non-smoking” What the service does well: Island Place continues to provide a comfortable accommodation to suit the needs and choice of lifestyle to people living there. Service users are not restricted in how they spend their day; from the time, they wake up to going out to accessing the community services for leisure and education. Service users receive care and support that they need, which promotes their independence. The rapport between the service users and staff is good and the atmosphere in the home is relaxed. Staff have a good awareness of the service users needs and the impact of their mental health and ways of supporting them. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are provided with information about the service although management details needs to be updated. The assessment process has improved, which involves the service users to ensure their care and support needs are met. EVIDENCE: Island Place has a ‘Statement of Purpose’ that details the range of service it offers which includes information as to who the service is for, the aims and objectives, the living arrangements and facilities and details the admission process. The complaints procedure is detailed including who should be contacted in case of any concerns along with contact details of the Advocacy services. Whilst there is a summary of staffing and training remain the same, the manager’s details should to be updated following the appointment of the Acting Manager. The content is detailed and the format is in easy to read style. Majority of the comment cards received indicated that service users had a choice about moving to Island Place, received information about the home and were given the option of visiting and having a trial stay, to see if it was the right place for them. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 9 Service users said they were asked about the care and supported needed during their stay at Island Place. Three service users’ care files viewed contained copies of the assessment of care needs carried out by the Care Management Team. All files contained a copy of the assessment of care needs key information such as medication, physical needs, emotional and mental health needs, medication and details of health professionals involved such as the Community Psychiatric Nurse. The Acting Manager has developed a basic assessment tool to record information from meeting with the service user such as the specific condition related needs and the management of risks, cultural or diverse needs, any aspirations or goals and establish the preference of care albeit residential care or semi-independent support. Service users whose care was tracked said they received information about Island Place and all had the opportunity to visit for the day, have an overnight stay or longer to make sure that the home was right for them. Staff said they have information about the new service user and meet them during the introductory or trial visits. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to make individual decisions in all aspects of their life that have a direct impact on the quality of care and support received. EVIDENCE: The care plans and records of three service users were viewed, of which two preferred semi-independent living support. The care plans outlined the individual resident’s needs and support required and interests in social, leisure and education activities, including timetables of activities at a centre attended by a service user. Whilst the care plans contain basic information about the individual care and support needs, specific diagnosis of their mental health, cultural needs and preference of lifestyle is unclear or not addressed. Comment incorporated from the comment card received in response to how the care home can improve, stated; “ongoing, continue to review the needs of clients and maintain training; no concerns at present”. Majority of the Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 11 comment cards indicated that service users made daily choices independently in relation to how they spend the day or supported by staff; indicated staff do treat them with respect; listened and acted on what they say. Comments incorporated in the comment cards included “I am treated and the staff are kind to me” and the staff do listen to me and do the best they can to help” and “ sometimes I find it hard to get my point of view over to others”. Any known risks to service users, measures to ensure their safety were identified, in relation to smoking, drinking alcohol that may have adverse effect with their medication, managing their medication and keeping sharp knives in the main kitchen and not in the flats. Service users wishes, interests and changes in the care and support needs are recorded in the daily records made by the staff on duty. The recordings are details and reflect the support given to the service users. Service users said they could not recall having formal meeting to discuss their care arrangement although were confident to tell the staff or the Acting Manager directly. Service user knew information about them was held in the office, could look at it if they chose to and knew it was kept confidential. The Acting Manager said following the findings from the Quality Assurance exercise and his appointment care plans are being updated. Staff said they still do not key work individual service user, but may do so in the future. Daily records are detailed to reflect decisions made by the service users such as went to the gym, attended REMIT, shopping or met with the Community Psychiatric Nurse. The daily recordings of incidents that had occurred and actions taken to support and make the situation safe, which was consistent accident and incident reports. Service users described the support they received which was consistent with the information received from that staff on duty and the daily records made by the staff. Observations were made of service users making decisions in what and how they spent the day; service users were seen doing their laundry, going to the local shops, the bank with a support worker and speaking with staff about particular matter that concerned them. Staff demonstrated an awareness of the service users daily routines, preferences, recognising if a service user was distressed and how they should support the service user. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can experience and participate in activities of interest and supported to maintain their daily routines and choice of lifestyle with the support. EVIDENCE: The service users tracked said they had no educational interests, although one service user attended activities at the Afro-Caribbean Centre and another previously did voluntary work and had made a coffee table. Other service users were seen spending time in their flats; used the gym facilities at the local leisure centre, went food shopping and to the bank with a Support Worker. A service user showed the Inspector the work done on the laptop computer and did not feel the need to attend college. Service users said they knew where to find staff if they were needed and would let them know if they were going out. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 13 At present Island Place does not at present have access to a minibus and staff support service users to use public transportation. However, the Acting Manager said Island Place would have access to transportation as the occupancy level increases. One service user receives 1:1 support, which allows them to participate and experience opportunities that would normally be restricted. Comments incorporated in the comment cards received included “if family visit they are made welcome” and “sometimes visit my mother or my mother visits me”. Service users observed appeared to have their own daily routines and preference of lifestyle. All flats and apartments are lockable and service users have keys to their flats and their bedrooms. The Community Psychiatric Nurse was seen leaving the home after sharing some information from meeting with the service user, although there was no opportunity to seek their opinion of the care provided at Island Place. Whilst some service users did their own laundry, others needed some prompting and assistance. Service users said the laundry room is kept locked now and is opened for use. Service users said they were asked and this was agreed, some clothes went missing. Service users said they knew about the rules for smoking and where they could smoke. Where service users consumed alcohol there were agreements in place to ensure the wellbeing of the service users whilst managing the potential risks. Fire extinguishers are close to the communal lounges where the service users are allowed to smoke. Service users have kitchen and dining facilities in the flats and can prepare their own meals if they choose. However, sharp knives are only kept in the main kitchen on the ground floor and service users can prepare their meals in the main kitchen. Meals are prepared by the trained staff and served in the social lounge and dining room. Staff said the majority of the service users that have the meals prepared do not have any special dietary needs. Service users were generally happy with the meals provided. Two service users tracked said they prepared their own meals; enjoy West Indian food and British food and preferences were recorded in the care plans. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to access health care needs and improved management of medication ensures their wellbeing. EVIDENCE: The current service users have varying levels of independence and support needed ranging from prompting to developing independent living skills. Service users described how the staff supports them and were confident that staff would understand their needs. Service users said they felt supported and generally respected by the staff, in the way they listen and help when asked. Whilst service users spoken with had very little or no contact with their family, contact with friends was supported. One service user said he visits friends in Nottingham, using public transport. Care records showed what if any religious or spiritual practices were observed and how staff needed to support the service user. Staff were knowledgeable about the level of support and prompting needed by the service users although no one required any assistance with personal care. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 15 One comment card was received from the General Practitioner, which indicated that any specialist advice was included in the care planning; medication was appropriately managed; had not received any complaints and was satisfied with the overall care provided to the service. Comment incorporated in the comment card received in response to what the service does well; “support with attending appointment” and “encourage/ support/guide clients to be independent”. Service users said a Dentist visited them all for a check-up at the home. Service users care records showed visits, appointments attended and details of any treatment or instruction given by the General Practitioner, District Nurse and the Community Psychiatric Nurse. One service user said they managed their diabetes, with a good diet, medication and attended regular health appointments, which was consistent with the care records. The medication is stored in two locked cabinets and kept secure in the office. Acting Senior Support Worker and the Acting Manager are trained to administer medication. The Acting Senior Support Worker described the management of medication including supporting service users that selfmedicate. A service user who self-medicates, showed the Inspector where the medication is kept locked in his bedroom. Management, receipt, storage and recording of medication has improved by good communication and accurate recording. When errors in recording occur this is now logged and shared with staff at the handover meetings. Procedures are in place to administer controlled medication that requires two trained staff. Medication for service users were checked against the medication records and found to be correct and up to date. Service users were observed receiving the medication individually and knew what medication the take. The Acting Manager said that following the Quality Assurance exercise; an audit of the management medication has been requested from the Pharmacist. The Acting Manager was aware of the concern raised by the Community Psychiatric Nurse, which was addressed by the previous manager. Subsequently, the Acting Manager nominated six staff from the day and night team to attend refresher medication training. Staff training matrix showed the staff that had completed training in safe administration of medication. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by complaints processes and by staff trained in home’s policies and procedures. EVIDENCE: The complaints procedure is displayed in reception and included in the statement of purpose. Service users are informed of the home’s complaints procedure and given a copy when the move to the home. Service users said they felt confident to complain, express concerns to any member of staff or the Acting Manager. The comment cards received from the service users confirmed they were aware of the home’s complaints procedure and were confident to approach staff or the manager. Island Place uses a form to record complaints and concerns. Records showed that Island Place had received four complaints from service users since the last inspection. The records showed the resulting actions taken. However, the concern initially brought to the attention of the Commission for Social Care Inspection and referred to the home to address, was not recorded. Although the Acting Manager was unable to confirm the actions taken, as he was not in post, he did confirm staff were nominated further medication training. Two members of staff demonstrated their awareness of the policies and procedures, which they should follow should they have any concerns as to a Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 17 resident’s welfare, allegation or suspicion of abuse. Staff said they would have no hesitation to report or whistle-blow, poor or bad care practices of a colleague. Staff said safeguarding adults’ training was part of the induction training, which outlines their responsibilities about care practice issues. The Inspector observed the practice followed when service users asked for their money, held in the office for safekeeping. The Acting Manager recorded the money given to the service user and recorded the balance, which was signed by the service user. Another service user felt they were able to manage their money better with the support from the staff. This confirmed arrangement was in place to manage resident’s finances and demonstrated there is a clear procedure for handling money. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have the choice of living arrangements that is comfortable, safe and maintained. EVIDENCE: Island Place offers residential and semi-supported living type of accommodation. There is CCTV in operation in the main entrance and stairways leading to the lobby of the flats, which does not invade service users’ privacy. All the flats accommodate up to four service users have individual bedrooms, kitchen and dining room, a communal lounge and shower/toilet facilities. There is a large communal lounge on the ground floor adjacent to the main kitchen and close to the laundry room. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 19 The Inspector was invited to view a service user’s flat and apartment. The living area was shared with between three service users. Two of the service users said the flat was personalised, comfortable, spacious and manageable for them. Bedrooms had wash hand basins and matching bedroom furniture. Whilst one service user said they needed minimal support to keep their living area tidy, another service user said he needed reminding. Majority of the comment cards received from service users indicated that the home was fresh and clean. The laundry room is on the ground floor and it kept locked when not in use. Some service users said they needed help with their laundry, whilst others were able to manage themselves. Staff said cleaning materials is kept locked and service users are supported to ensure they are safe. Staff were aware why some service users were at risk and what procedures are followed to control infection and managing waste or spillages. Staff training records confirmed staff had received training in health and safety and infection control. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by good recruitment processes and trained staff that ensures their care and social needs are met individually and safely. EVIDENCE: The staff team are experienced in working with people with mental health and working to support service users to be independent. The staff team observed and spoken with demonstrated a commitment to supporting the service users. Throughout the site visit, staff were observed responding and supporting service users when asked, and letting them spend the day as they choose to. The number of staff on duty at any one time was excluding the Acting Manager and was consistent with the staff on duty. The Acting Manager said staffing would increase as more service users move to the home. Staff said they had a clear understanding of their responsibility towards the service users at the home in terms of their wellbeing and supporting them. Communication between the staff team has improved, through good record keeping, information shared through the communication book and at handover meetings Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 21 even though there is no key-working system in place. Service users said the staff were approachable, supportive and understood them. Island Place has a good recruitment procedure, supported by the human resource team. Three staff personnel files examined, including a new Support Worker, which demonstrated the recruitment procedure had been followed with satisfactory pre-employment checks such as references, protection of vulnerable adults (POVA) first checks and the criminal records bureau (CRB). Staff as part of their recruitment and induction process, are given a copy of the General Social Care Council Standards of Conduct and a job description outlining their roles and responsibilities within Island Place. The staff training records submitted as part of the pre-inspection questionnaire detailed the training completed by the staff at Island Place and the certificates seen in the staff files confirmed this. Training included 12 week induction programme; moving and handling, health and safety, policies and procedures, food hygiene, first aid, adult protection procedures, COSHH; NAPPI (non-abusive psychological and physical intervention training, specific to working with people with mental health issues ad fire safety. The Acting Manager confirmed 46 of staff that had already attained a National Vocational Qualification (NVQ) in Care, level 2 and above. The Acting Manager has already attained NVQ level 4, Registered Manager’s Award. The Acting Senior Support Worker and the new Support Worker said they had received regular supervision as part of their induction. Staff said they could approach the Acting Manager at any time and recently has had to be called out of hours to deal with an incident. The Acting Manager acknowledged that regular there was no planned staff supervision and team meetings’ although had met with all the staff individually and collectively, since being appointed. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 40, 41 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users health, safety and welfare is promoted and protected by being consulted and the improvements made in the management of the home. EVIDENCE: The Acting Manager has been in post seven weeks and is completing the registration process with the Commission for Social Care Inspection. The Registered Manager has experience of working and managing a care home for people with mental health within Prime Life Group and has attained the National Vocation Qualification, level 4, Registered Manager’s Award. The Acting Manager had clear understanding of the responsibility in managing the home. Staff and service users were seen approaching the Acting Manager Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 23 offered the support, direction and acted on requests such as service user wanting access to their money. On the day of the site visit to Island Place, the staffing and management of the home appeared to be organised. Staff had clear direction, roles and responsibilities in relation to providing care to residents and day-to-day running of the home. Observations made on the day demonstrated the staff are caring and supportive towards the service users. A Quality Assurance exercise was carried out at the home in November 2006 and the report was sent to the Commission for Social Care Inspection. The report showed service users and staff views were sought, records such as care plans; risk assessments and staff recruitment, supervision, team meetings and training were checked. The report concluded with an action plan to be addressed by the Registered Manager at the time. The Acting Manager said work had started to address the care planning, introducing key-working systems, improving the management of medication, cleanliness in the home, improving the social programme, increasing occupancy levels, staff supervision, team meetings and for staff commence the NVQ training in care. This was good evidence that Prime Life Group regulates Island Place and undergoes a system of quality assurance measured against the National Minimum Standards, whilst seeking the views of the people receiving the care. Residents and staff records viewed were kept in good order, care plans, comprehensive daily records, stored securely and were available for the purpose of the inspection visit. Staff were aware of where information, incident and accident record, policies, and procedures are kept. The monthly visits carried out by a representative from within the Prime Life Group, acting on behalf of the Registered Person. The Inspector viewed the recent monthly visit reports, which included speaking with the residents and visitors, viewed records, speaking with staff on duty, viewing the environment and following upon issues identified at the previous visit. The Inspector randomly examined health and safety records, which showed regular fire testing and checks were carried out. Cleaning materials are stored safely. Service users and staff described what they do if the fire alarm sounds. Staff confirmed fire alarm tests are carried out on Sundays and records confirmed this. Staff training records viewed showed all staff had received training in health and safety and fire safety. The maintenance person visits the home on Wednesdays’ and staff in the workbook records any reported faults needing attention. The accidents/ incidents records viewed were consistent with the reports submitted to the Commission for Social Care Inspection, detailing actions taken to avoid a reoccurrence. Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Island Place DS0000066589.V335608.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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